Provider Demographics
NPI:1689057903
Name:CREECH, KAILEY D (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:D
Last Name:CREECH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 STATE ST E
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3806
Mailing Address - Country:US
Mailing Address - Phone:727-243-9475
Mailing Address - Fax:
Practice Address - Street 1:502 STATE ST E
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677
Practice Address - Country:US
Practice Address - Phone:727-243-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 14170235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16172500Medicaid